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Illustrated Textbook of

Paediatrics

When the late Frank A. Oski wrote the foreword for the first edition of this book in 1997, he gave it generous praise and predicted that it would become a ‘standard by which all other medical textbooks will be judged’. He was a great man and a wonderful writer, so his prediction was no doubt welcomed by the editors, Tom Lissauer and Graham Clayden, both well known for their contribution to undergraduate and postgraduate medical education and assessment.

I have a much easier task in writing the foreword for the fifth edition. The mere fact that there is a fifth edition is testimony in itself, but there is also the fact that this book has become the recommended paediatric textbook in countless medical schools throughout the world and has been translated into 12 languages. I have travelled the world over the last 20 years and wherever I have been in a paediatric department, the distinctive sunflower cover of Lissauer’s Illustrated Textbook of Paediatrics has been there with me. Whether it is Hong Kong, Malaysia, Oman, or South Shields, it is there!

It is not surprising that it has won major awards for innovation and excellence at the British Medical Association and Royal Society of Medicine book awards. The book is well established and widely read for the simple reason that it is an excellent book. Medicine is now so complex and information so vast that students are no longer expected to know all there is to know about medicine. What they need are the core principles and guidance as to where to find out more. This book not only gives the core principles, but also provides a great deal more for the student who wishes to extend his or her knowledge. It is in a very accessible form and has a style and layout which facilitates learning. There are many diagrams, illustrations and case histories to bring the subject to life and to impart important messages. This new edition includes summaries to

Foreword

help revision and there is also a companion book for self-assessment.

This edition has a new editor, Will Carroll, who has succeeded Graham Clayden, and is also a paediatrician with great expertise in medical education and assessment. He has helped ensure that the book continues to provide the paediatric information medical students need. It has been thoroughly updated and has many new authors, each of whom is an expert in their field and who has been chosen because of their ability to impart the important principles in a non-specialist way. The book continues to focus on the key topics in the undergraduate curriculum, and in keeping with this aim there are new, expanded chapters on child protection and global child health.

There are now countless doctors throughout the world for whom this textbook has been their introduction to the fascinating and rewarding world of paediatrics.

For students, it is all they need to know and a bit more. For postgraduates, it provides the majority of information needed to get through postgraduate examinations. It stimulates and guides the reader into the world of clinical paediatrics, built on the sound foundation of the knowledge base provided by this book.

The editors are to be congratulated on the continuing success of this book.

I can only echo what Frank Oski said in his preface to the first edition: ‘I wish I had written this book’!

Professor Sir Alan Craft Emeritus Professor of Child Health, Newcastle University Past President Royal College of Paediatrics and Child Health

Helen E Foster MB BS MD FRCPCH

FRCP DCH CertClinEd

Professor of Paediatric Rheumatology, Newcastle University and Honorary Consultant in Paediatric Rheumatology, Great North Children’s Hospital, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK

28. Musculoskeletal disorders

Andrea Goddard MB BS MSc FRCPCH

Consultant Paediatrician, Imperial College Healthcare NHS Trust and Honorary Senior Lecturer in Paediatrics, Imperial College London, UK

8. Child protection

Anu Goenka MB ChB BSc DFSRH

DTM&H MRCGP MRCPCH

Clinical Research Fellow, Manchester Collaborative Centre for Inflammation Research, University of Manchester, Manchester, UK and Honorary Specialist Registrar in Paediatric Immunology, Royal Manchester Children’s Hospital, Manchester, UK

31. Global child health

Jane Hartley MB ChB MRCPCH MMedSc PhD

Consultant Paediatric Hepatologist, Birmingham Children’s Hospital, Birmingham, UK

21. Liver disorders

David P. Inwald MB BChir PhD FRCPCH

Consultant Paediatrician and Honorary Senior Lecturer in Paediatric Intensive Care, Imperial College Healthcare NHS Trust, London, UK

6. Paediatric emergencies

Elisabeth Jameson MBBCh BSc MSc MRCPCH

Consultant in Paediatric Inborn Errors of Metabolism, Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, St Marys Hospital, Manchester, UK

27. Inborn errors of metabolism

Sharmila Jandial MBChB MRCPCH MD

Consultant Paediatric Rheumatologist, Great North Children’s Hospital, Newcastle upon Tyne, UK and Honorary Clinical Senior Lecturer, Newcastle University, UK

28. Musculoskeletal disorders

Huw Jenkins MB BChir MA MD FRCP

FRCPCH DL

Consultant Paediatric Gastroenterologist, Children’s Hospital for Wales, Cardiff, UK

14. Gastroenterology

Deirdre Kelly MD FRCP FRCPI FRCPCH

Professor of Paediatric Hepatology, Birmingham Children’s Hospital, Birmingham, UK

21. Liver disorders

Larissa Kerecuk MBBS BSc FRCPCH

Consultant Paediatric Nephrologist, Birmingham Children’s Hospital, Birmingham, UK

19. Kidney and urinary tract disorders

Anthony Lander PhD FRCS (Paed) DCH

Consultant Paediatric Surgeon, Birmingham Children’s Hospital, Birmingham, UK

14. Gastroenterology

Tom Lissauer MB BChir FRCPCH

Honorary Consultant Paediatrician, Imperial College Healthcare Trust, London, UK and Centre for International Child Health, Imperial College London, UK

2. History and examination

5. Care of the sick child and young person

10. Perinatal medicine

11. Neonatal medicine

20. Genital disorders

Andrew Long MA MB FRCP FRCPCH FAcadMEd DCH

Vice President (Education), Royal College of Paediatrics and Child Health; Consultant Paediatrician, Great Ormond Street Hospital, London, UK

5. Care of the sick child and young person

Chloe Macaulay BA MBBS MRCPCH MSc PGCertMedEd

Consultant Paediatrician, Evelina London Children’s Hospital, London UK

2. History and examination

Janet McDonagh MB BS MD

Senior Lecturer in Paediatric and Adolescent Rheumatology, Centre for Musculoskeletal Research, University of Manchester, UK

30. Adolescent medicine

List of Contributors

MRCPCH

Paediatric Emergency Consultant, Bristol Royal Hospital for Children, Bristol, UK

31. Global child health

Daniel Morgenstern MB BChir PhD

FRCPCH

Staff Physician – Solid Tumor Program, Assistant Professor, Department of Paediatrics, University of Toronto, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada

22. Malignant disease

Rob Primhak MD FRCPCH

Consultant Paediatric Respiratory Physician (ret), Sheffield Children’s Hospital, Sheffield, UK

17. Respiratory disorders

John Puntis BM DM FRCP FRCPCH

Consultant in Paediatric Gastroenterology and Nutrition, Leeds Teaching Hospitals NHS Trust, Leeds, UK

13. Nutrition

Irene A.G. Roberts MD FRCPath

Professor of Paediatric Haematology, Oxford University Department of Paediatrics, John Radcliffe Hospital, Oxford, UK

23. Haematological disorders

Damian Roland BMedSci MB BS

MRCPCH PhD

Consultant and Honorary Senior Lecturer in Paediatric Emergency Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK

5. Care of the sick child and young person

Don Sharkey BMedSci BM BS PhD

FRCPCH

Associate Professor of Neonatal Medicine, University of Nottingham, Nottingham, UK

10. Perinatal medicine

11. Neonatal medicine

Diane P.L. Smyth MD FRCP FRCPCH

Honorary Consultant Paediatric Neurologist / Neurodisability, Imperial College Healthcare NHS Trust, London, UK

3. Normal child development, hearing and vision

Marc Tebruegge DTM&H MRCPCH MSc

FHEA MD PhD

NIHR Clinical Lecturer in Paediatric Infectious Diseases & Immunology, Academic Unit of Clinical & Experimental Sciences, The University of Southampton, Southampton, UK

15. Infection and immunity

Tracy Tinklin BM FRCPCH

Consultant Paediatrician, Derbyshire Childrens Hospital, Derby, UK

12. Growth and puberty

26. Diabetes and endocrinology

Robert M. Tulloh BM BCh MA DM FRCP FRCPCH

Professor, Congenital Cardiology, University of Bristol, Bristol, UK and Consultant Paediatric Cardiologist, Bristol Royal Hospital for Children, Bristol, UK

18. Cardiac disorders

Ian Tully MBBCh MRCPCH

Academic Clinical Fellow in Genomic Medicine, Cardiff University & University Hospital of Wales, Cardiff, UK

9. Genetics

Julian Verbov MD FRCP FRCPCH CBiol FSB FLS

Honorary Professor of Dermatology, University of Liverpool; Consultant Paediatric Dermatologist, Royal Liverpool Children’s Hospital, Liverpool, UK

25. Dermatological disorders

Premila Webster MBBS DA MSc

MFPHM FFPH DLATHE DPhil

Director of Public Health Education & Training, Nuffield Department of Population Health, University of Oxford, Oxford, UK

1. The child in society

William P Whitehouse MB BS BSc FRCP FRCPCH

Clinical Associate Professor and Honorary Consultant Paediatric Neurologist, University of Nottingham and Nottingham Children’s Hospital, Nottingham University Hospital’s NHS Trust, Nottingham, UK

29. Neurological disorders

Lisa Whyte MBChB MSc

x

4. Developmental problems and the child with special needs

Consultant Paediatric Gastroenterologist, Birmingham Children’s Hospital, Birmingham, UK

14. Gastroenterology

Bhanu Williams MB BS BMedSci

MRCPCH DTMH BA MAcadMed

Consultant in Paediatric Infectious Diseases, London North West Healthcare NHS Trust, Harrow, UK

31. Global child health

Clare Wilson BA MBBChir MRCPCH

Academic Clinical Fellow, Institute of Child Health, University College London, UK

6. Paediatric emergencies

Neil Wimalasundera MBBS MRCPCH MSc

Consultant in Paediatric Neurodisability, The Wolfson Neurodisability Service, Great Ormond Street Hospital, London, UK

3. Normal child development, hearing and vision

4. Developmental problems and the child with special needs

The editors would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without whom this new edition would not have been possible as we have widely reused their contributions.

The child in society Dr Rashmin Tamhne, Prof Mitch Blair, Dr Peter Sidebotham

History and examination Prof Dennis Gill, Dr Graham Clayden, Prof Tauny Southwood, Dr Siobhan Jaques, Dr Sanjay Patel, Dr Kathleen Sim

Normal child development, hearing, and vision Dr Angus Nicoll

Developmental problems and the child with special needs Dr Richard W Newton

Care of the sick child and young person Prof Raanan Gillon, Dr Graham Clayden, Prof Ruth Gilbert, Dr Maude Meates, Dr Vic Larcher

Paediatric emergencies Dr Nigel Curtis, Prof Nigel Klein, Dr Simon Nadel, Dr Rob Tasker, Dr Shruti Agrawal

Accidents and poisoning Prof Jo Sibert, Dr Barbara Phillips, Dr Ian Maconochie, Dr Rebecca C Salter

Child protection Prof Jo Sibert, Dr Barbara Phillips

Genetics Dr Elizabeth Thompson, Dr Helen Kingston

Perinatal medicine Dr Karen Simmer, Prof Michael Weindling, Prof Andrew Whitelaw, Prof Andrew R Wilkinson

Neonatal medicine Dr Karen Simmer, Prof Michael Weindling, Prof Andrew Whitelaw, Prof Andrew R Wilkinson

Growth and puberty Dr Tony Hulse, Dr Jerry K H

Wales

Nutrition Prof Ian Booth, Dr Jonathan Bishop, Dr Stephen Hodges

Acknowledgements

Gastroenterology Dr Jonathan Bishop, Dr Stephen Hodges

Infection and immunity Prof Nigel Klein, Dr Nigel Curtis, Dr Hermione Lyall, Dr Andrew Prendergast, Dr Gareth Tudor-Williams

Allergy Dr Tom Blyth, Prof Gideon Lack

Respiratory disorders Dr Jon Couriel, Dr Iolo Doull, Dr Malcolm Brodlie, Dr Michael C McKean, Mr Gerard P S Siou

Cardiac disorders Prof Andrew Redington

Kidney and urinary tract disorders Prof George Haycock, Dr Lesley Rees

Genital disorders Mr Nicholas Madden, Mr Mark Stringer, Prof David Thomas, Mrs Aruna Abhyankar

Liver disorders Dr Ulrich Baumann, Dr Jonathan Bishop, Dr Stephen Hodges

Malignant disease Prof Michael Stevens, Dr Helen Jenkinson

Haematological disorders Dr Lynn Ball, Prof Paula Bolton-Maggs, Dr Michelle Cummins

Child and adolescent mental health Prof Peter Hill, Prof Elena Garralda, Dr Sharon E Taylor, Dr Cornelius Ani

Dermatological disorders Dr Gill Du Mont

Diabetes and endocrinology Dr Tony Hulse, Dr Jerry K H Wales

Metabolic disorders Dr Ed Wraith

Musculoskeletal disorders Dr John Sills, Prof Tauny Southwood

Neurological disorders Dr Richard W Newton, Dr Alison Giles

Adolescent medicine Dr Terry Segal, Prof Russell Viner

Global child health Prof Stephen J Allen, Dr Ike Lagunju, Raúl Pardíñaz-Solís

Regarding the society in which we live:

• in combination with our genes, it determines who we are

• it is responsible for the country’s health outcomes – which is why the infant mortality in the UK is 3.8 per 1000 live births, but in Sweden is 2.7 whilst in Bangladesh it is 47 and in Malawi 77 per 1000 live births

• important public health issues for children and young people in the UK are reduction in mortality, health inequalities, variations in health outcomes, obesity, emotional and behaviour problems, teenage pregnancy, smoking and drug abuse, and improving child protection services

• many of the causes and determinants of childhood morbidity and mortality are preventable. Doctors can play a role by raising society’s awareness of how this can be achieved and improving the health systems and healthcare services they provide.

Most medical encounters with children involve an individual child presenting to a doctor with a symptom, such as difficulty breathing or diarrhoea. After taking a history, examining the child and performing any necessary investigations, the doctor arrives at a diagnosis or differential diagnosis and makes a management plan. This disease-oriented approach, which is the focus of most of this book, plays an important part in ensuring the immediate and long-term well-being of the child. Of course, the doctor also needs to understand the nature of the child’s illness within the wider context of their world, which is the primary focus of this chapter.

In order to be a truly effective clinician, the doctor must be able to place the child’s clinical problems within the context of the family and of the society in which they live.

Important goals for a society are that its children and young people are healthy, safe, enjoy life, make a

The child in society

positive contribution and achieve economic well-being (Every Child Matters, 2003 at: http://www.dcsf.gov.uk/ everychildmatters). This chapter will focus on environmental factors that affect children in the UK and other high-income countries. Those in low and middleincome countries are considered in Chapter 31, Global Child Health.

The child’s world

Children’s health is profoundly influenced by their social, cultural and physical environment. This can be considered in terms of the child, the family and immediate social environment, the local social fabric and the national and international environment (Fig. 1.1). Our ability to intervene as clinicians needs to be seen within this context of complex interrelating influences on health.

The child

The child’s world will be affected by gender, genes, physical health, temperament and development. The impact of the social environment varies markedly with age:

• Infant or toddler: life is mainly determined by the home environment

• Young child: in addition to home environment by school and friends

• Young person: physical and emotional changes of adolescence, but also aware of and influenced by events nationally and internationally, e.g. in music, sport, fashion or politics.

Immediate social environment

Family structure

Although the ‘two biological parent family’ remains the norm, there are many variations in family structure. In

Figure 1.1 A child’s world consists of overlapping, interconnected and expanding socioenvironmental layers, which influence children’s health and development. (After Bronfenbrenner U. 1979. Contexts of child rearing – problems and prospects. American Psychologist 34:844–850.)

The child in society 1

the UK, the family structure has changed markedly over the last 30 years (Fig. 1.2).

Single-parent households – One in four children now live in a single-parent household (91% living with their mother). Disadvantages of single parenthood include a higher level of unemployment, poor housing and financial hardship (Table 1.1). These social adversities may affect parenting resources, e.g. vigilance about safety, adequacy of nutrition, take-up of preventive services such as immunization and regular screening, and ability to cope with an acutely sick child at home.

Reconstituted families – The increase in the number of parents who change partners and the

Figure 1.2 Changing structure of the family 1971–2014. (ONS, General Lifestyle Survey 2016).

accompanying rise in reconstituted families (1 in 10 children live in a step-family) mean that children are having to cope with a range of new and complex parental and sibling relationships. This may result in emotional, behavioural and social difficulties.

Looked after children – The term ‘looked after children’ is generally used to mean those children who are looked after by the state. Approximately 3% of children under 16 years old in the UK live away from their family home. Children enter care for a range of reasons including physical, sexual or emotional abuse, neglect or family breakdown. There are currently over 92 000 children in care in the UK. They have significantly increased levels of health

Travel

The increasing ease of travel can broaden children’s horizons and opportunities. Especially in rural areas, the ease and availability of transport allow greater access to medical care and other services. However, the increasing use of motor vehicles contributes to the large number of injuries sustained by children from road traffic accidents, mainly as pedestrians. It also decreases physical activity, as shown by the high proportion of children taken to school by car. Whereas 80% of children in the UK went to school by foot or bicycle in 1971, only 42% of children aged 5–16 years walked to school in 2013. This contributes to the rise in childhood obesity.

National and international environment

Economic wealth

In general, there is an inverse relationship between a country’s gross national product and income distribution and the quality of its children’s health. The lower the gross national income:

• the greater the proportion of the population who are children

• the higher the childhood mortality.

However, as described above, even in countries with a high gross national product, many children live in poverty.

In all countries, including those with high gross national product, difficult choices need to be made about the allocation of resources. Difficult decisions also have to be faced in deciding the affordability of very expensive procedures, such as heart or liver transplantation, neonatal intensive care for extremely premature infants and certain drugs, such as genetically engineered enzyme replacement therapy for Gaucher disease or cytokine modulators (‘biologics’) and other immunotherapies. The public are becoming more engaged in these debates.

Media and technology

The media has a powerful influence on children. It can be positive and educational. However, the impact of television and computers and mobile technology can be negative owing to reduced opportunities for social interaction and active learning, lack of physical exercise and exposure to violence, sex, and cultural stereotypes. The extent to which the aggressive tendencies of children may be exacerbated or encouraged by media exposure to violence is unclear.

The internet is enabling parents and children to become better informed about and gain support for their children’s medical problems. This is especially beneficial for the many rare conditions encountered in paediatrics. A disadvantage is that it may result in the dissemination of information which is incorrect or biased, and may result in requests for inappropriate or untested investigations or treatment.

War and natural disasters

Children are especially vulnerable when there is war, civil unrest or natural disasters. Not only are they at greater risk from infectious diseases and malnutrition but also they may lose their caregivers and other members of their families and are likely to have been exposed to highly traumatic events. Their lives will have been uprooted, socially and culturally, especially if they are forced to flee from their homes and become refugees. Recently, the huge increase in the number of refugee children following war and ethnic violence in parts of the Middle East, South-East Asia and Africa, with families displaced internally or in other countries, often in refugee camps, is resulting in deterioration in even their basic health outcomes.

Well-being

The concept of well-being encompasses a number of different elements and includes emotional, psychological and social well-being. The well-being of children is key to the development of healthy behaviours and educational attainment and impacts on their childhood and life chances and on their families and communities. The Children’s Society survey in 2014 found that 9% of children in the UK (aged 8–15 years) report low life satisfaction. Having low satisfaction increases with age, rising from just 4% of 8 year olds to 14% of 15 year olds. There is a gender gap, with girls tending to report lower well-being than boys. Having a low level of well-being appears to be related to sociodemographic factors such as household income and family structure. Children who have recently been bullied also report a lower level of well-being. One of the most important factors in promoting children’s well-being appears to be the quality of family relationships and parental behaviours and in particular the availability of emotional support. Interventions which can result in improvement in childhood well-being include parenting support programmes, emotional health and well-being programmes in schools, access to green spaces and opportunities to be active. Children in the UK do much worse in terms of well-being compared with other European countries and across the world.

Important public health issues for children and young people

Important public health issues for the 11 million children and young people in the UK include reduction in mortality, health inequalities, child protection, obesity, emotional and behaviour problems, disability, smoking and drug abuse.

Child mortality (Fig. 1.4)

In 1900–1902, 146 out of every 1000 children born in England and Wales would die before their first birthday, by 1990–1992 the rate had fallen to 7 deaths per 1000 live births and to 3.8 per 1000 live births in 2013. This dramatic reduction in childhood mortality over the last

Mortality (per 1000 live births)

<1 year

Mortality per 100,000 population of same age

1–4 years 5–9 years 10–14 years

The child in society 1

century was primarily due to improvements in living conditions such as better sanitation and housing and access to food and clean water. There has also been a marked reduction in childhood deaths from infectious disease, augmented by the increased range and uptake of immunizations.

Currently over half of deaths in childhood in the UK occur during the first year of life. Prematurity and/or low birthweight contribute considerably to infant mortality. The wide variation in the proportion of babies born preterm between countries, almost 8% in the UK, 12% in the USA, but only 5.5% in Finland and 5.9% in Sweden is of uncertain origin, but is likely to be predominantly environmental. This wide variation in prematurity rate has a marked effect on infant mortality rate and outcomes. Infant mortality rates for very low birthweight babies (<1500 g) and low birthweight babies (<2500 g) are 164 and 32.4 deaths per 1000 live births respectively. This is much higher than the 1.3 deaths per 1000 live births among babies of normal birthweight (>2500 g).

Environmental factors that influence infant mortality include:

• maternal age – infant mortality rates are lowest for babies of mothers aged 25–29 years (3.4 per 1000 live births) and highest for mothers aged under 20 years (6.1 per 1000 live births)

• maternal country of birth – for babies of mothers born outside the UK, the infant mortality rate is 4.2 compared with 3.8 per 1000 live births for mothers born in the UK

• social class – in 2013, infant mortality rates were highest for those in routine and manual occupations, the long term unemployed and those who have never worked and lowest for those in higher managerial and professional occupations.

Amongst 1–9 year olds the main causes of death are injuries and poisoning, cancer, and congenital anomalies. Sociodemographic factors are important in mortality from injuries and poisoning and from congenital

Figure 1.4

Marked reduction in childhood deaths between 1900 and 2012 in the UK. This is shown as deaths by age group per 100 000 population of the same age and infant mortality per 1000 live births.

anomalies, though they are usually poorly understood. A good example of the role of sociodemographic factors in congenital anomalies is neural tube defects. Their prevalence varies markedly between different countries; maternal nutrition, particularly with folic acid, as well as genetic factors play a role. In addition, the birth prevalence of neural tube defects is affected by antenatal screening practices and attitudes towards termination of pregnancy if an affected fetus is identified. Between the ages of 10 to 14 the most common causes of death in the UK are injuries and poisoning and cancer. Their mortality rate has declined over the last 50 years (see Fig. 30.2).

Comparison with other European countries

Although childhood mortality rates have declined over the past three decades, the UK continues to have a much higher child mortality rate compared with some other European countries. In 2013, the under 5 mortality rate for the UK was 4.9 deaths per 1000 live births, compared with 3.7 deaths per 1000 live births in France and 2.7 deaths per 1000 live births in Sweden. The reasons for this are complex, but it is in part due to the UK having higher rates of low birthweight and preterm rates when compared with some other European countries, both of which have a strong influence on infant mortality rates. In addition, the UK has one of the highest rates of child poverty compared with other comparable wealthy countries. Childhood mortality rates are higher in countries with a high proportion of deprived households. The Nordic countries have low levels of deprivation and also show some of the lowest child mortality rates. There is also evidence that the UK performs less well in the recognition and management of serious illness in primary and secondary care and in the community. In addition, outcome measures for chronic illnesses such as asthma, epilepsy and diabetes are poorer. More effective prevention and better medical care of these children could reduce mortality and morbidity.

History and examination

Features of history and examination in paediatric practice are:

• in contrast to adult medicine, the questions asked in the history and the way the examination is conducted need to be adjusted according to the child’s age

• examination is opportunistic, e.g. listening to the chest and heart in an infant or young child when quiet, or may require distraction or play

• in order to achieve a successful and complete examination in young children, ingenuity is often required

• parents are acutely concerned and anxious about their children – they quickly recognize and appreciate doctors who demonstrate interest, empathy, and skill.

Despite advances in technology and the availability of ever more sophisticated investigations, history-taking and clinical examination continue to be the cornerstone of clinical practice. These skills are even more crucial in paediatrics, where most diagnoses are made on the basis of a good history, augmented by astute observation of the child and targeted examination. When considering clinical history and examination of children, it is helpful to think about some of the common clinical presentations in which children are seen by doctors, and also the age of the child involved. All have an impact on the history taking and examination process.

Common clinical scenarios are:

• an acute illness, e.g. respiratory tract infection, a febrile child, appendicitis

• a chronic problem, e.g. faltering growth, constipation

• a newborn infant with a congenital malformation or abnormality, e.g. developmental dysplasia of the hip, Down syndrome

• suspected delay in development, e.g. delayed walking or speech

• behavioural problems, e.g. temper tantrums, hyperactivity, eating disorders.

The aims and objectives of all clinical encounters are to:

• establish the relevant facts of the history; this is usually the most fruitful source of diagnostic information – a parent’s description of an event provides valuable information

• elicit all relevant clinical findings

• collate the findings from the history and examination

• formulate a working diagnosis or differential diagnosis

• assemble a problem list and management plan.

Key features in a paediatric history and examination are:

• the child’s age – this is crucial in the history and examination (Fig. 2.1) as it determines:

– the nature and presentation of illnesses, developmental or behavioural problems

– the way in which the history-taking and examination are conducted

– the way in which any subsequent management is organized

• the nature of the problem – assessment of the acutely ill child will need to be more focused and concise (“how unwell is this child at this particular moment?”), whereas a developmental assessment will require detailed evaluation

• observing the child – their appearance, behaviour, play, and gait. The continued observation of the child during the whole interview may provide important clues to diagnosis and management.

History and examination

Infant

Neonate (<4 weeks)

Infant (<1 year)

Toddler

Approx 1-2 years

Preschool

Young child (2-5 years)

School-age

Teenager

Older child Adolescent

Figure 2.1 The illnesses and problems children encounter are highly age-dependent. The child’s age will determine the questions you ask on history-taking; how you conduct the examination; the diagnosis or differential diagnosis and your management plan.

Paediatrics stretches from newborn infants to adolescents. Whenever you consider a paediatric problem, whether medical, developmental or behavioural, first consider “What is the child’s age?”

To maximize the value of each consultation it is important to organize the environment so that it is welcoming and unthreatening. Have suitable toys or activities available. Avoid desks or beds between you and the family.

Parents or carers know their children best – never ignore or dismiss what they say.

Taking a history

Introduction

• Make sure you have read any referral letter and/or hospital notes before the start of the consultation.

• When you greet the child, parents, and siblings, check that you know the child’s first name and gender. Ask how the child prefers to be addressed.

• Introduce yourself.

• Determine the relationship of the adults to the child.

• Establish eye contact and rapport with the family, but keep a comfortable distance. Infants and some toddlers are most secure in parents’ arms or laps. Young children may need some time to feel at ease.

• Observe how the child plays and interacts with any siblings present.

• Do not forget to address questions to the child, when appropriate.

• There will be occasions when the parents will not want the child present or when the child should be seen alone. This is usually to avoid embarrassing older children or teenagers or young adults to impart sensitive information. This must

be handled tactfully, often by negotiating to talk separately to each in turn. Give an adolescent the opportunity to talk to you alone. This can be introduced as “It is my usual practice to …” See the adolescent after the parents so he/she knows that confidential information imparted to the doctor has not been disclosed.

Presenting symptoms

Full details are required of the presenting symptoms. Start with an open question. Let the parents and child recount the presenting complaints in their own words and at their own pace. Note the parent’s words about the presenting complaint: onset, duration, previous episodes, what relieves/aggravates them, time course of the problem, if getting worse and any associated symptoms. Has the child’s or the family’s lifestyle been affected? What has the family done about it? If describing a rash or an event such as a seizure, parents may have a photograph or video on their mobile phone. These can be very helpful, but you may need to ask for them!

Make sure you know:

• what prompted the referral

• what the parents think or fear is the matter. Have the parents been searching the internet or discussed it with others?

The scope and detail of further history taking are determined by the nature and severity of the presenting complaint and the child’s age. While the comprehensive assessment listed here is sometimes required, usually a selective approach is more appropriate (Fig. 2.2). This is not an excuse for a short, slipshod history, but instead allows one to focus on the areas where a thorough, detailed history is required. For example, in a young child with delayed speech, a detailed birth